INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS IMCI. planning guide. Gaining experience with the IMCI strategy in a country

Transcription

1 WHO/CHS/CAH/99.1 ORIGINAL: ENGLISH idistr.: GENERAL INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS IMCI planning guide Gaining experience with the IMCI strategy in a country DEPARTMENT OF CHILD AND ADOLESCENT HEALTH AND DEVELOPMENT WORLD HEALTH ORGANIZATION

2 World Health Organization, 1999 This document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced and translated, in part or in whole, but not for sale nor for use in conjunction with commercial purposes. The views expressed in documents by named authors are solely the responsibility of those authors. Produced in collaboration with ACT International, Atlanta, Georgia, USA. Designed by minimum graphics Printed in Switzerland

3 Contents Abbreviations ix About planning for the IMCI strategy 1 1. Introduce the IMCI strategy Review initial information about the IMCI strategy Orient important groups and individuals to the IMCI strategy (orientation meeting) Establish an IMCI management structure Train key personnel to manage sick children according to the IMCI guidelines Ministry of Health endorses early implementation of the IMCI strategy 15 Overview of the IMCI early implementation phase Develop a national plan for the IMCI early implementation phase Gather information for planning the IMCI strategy Decide on organization and management and develop terms of reference for the IMCI Working Group Develop a national plan for the IMCI early implementation phase (conduct a national planning workshop) Discuss the place of the IMCI strategy in the national context Plan for sustainable organization and management, and adequate policy support for the IMCI strategy Plan how to link the IMCI strategy with ongoing health sector reforms Plan for improvement of skills of health staff Plan for adaptation Plan IMCI training courses for first-level health workers Plan for follow-up after training Consider possibilities for improving skills of referral-level health workers 36

4 iv IMCI PLANNING GUIDE Optional: Discuss how to introduce IMCI in pre-service training Plan for improvement in the health system Plan for availability of drugs and supplies needed for IMCI Plan for improving referral pathways and services Optional: Plan for organization of work in health facilities Plan for supervision Plan for linking IMCI classifications and the health information system Plan for improvement in family and community practices Plan documentation of early implementation Plan for selection of districts for early implementation Plan the budget for the IMCI early implementation phase Compile the national plan for the IMCI early implementation phase 55 Overview of steps of the IMCI planning process Adapt the generic IMCI guidelines and training materials Initiate adaptation Do adaptation tasks Adapt clinical guidelines Adapt feeding recommendations, determine local terms and develop the mother s counselling card Plan for consistency of messages about child health communicated to families Circulate adapted guidelines for review and to build consensus Produce adapted training materials Adapt training materials to reflect the adapted guidelines and translate them Produce copies of adapted materials to use in the first central-level IMCI case management course Initiate activities to improve the health system and prepare for health worker training Initiate work of the Implementation Subgroup Initiate work with the district health teams Conduct an orientation meeting in each selected district (half day) Have individual meetings and discussions with key district persons 72

5 v CONTENTS Obtain information about the district that will be useful for planning Plan at the central level for follow-up after training, drug availability, improving referral pathways and services, supervision, linking IMCI classifications and the HIS, and documentation of the early implementation phase Plan for follow-up after training Plan for availability of drugs needed for implementation of IMCI Plan for improving referral pathways and services Plan for supervision Plan for linking IMCI classifications and the HIS Plan for documentation of early implementation Finalize arrangements for the first IMCI training course at central level Identify participants for the central-level IMCI case management course Prepare the central-level training site and obtain a course director, clinical instructor and facilitators Initiate activities to improve family and community practices Initiate work of the Family and Community Practices Subgroup Implement activities as agreed in the national planning workshop Collaborate with the Adaptation Subgroup to adapt feeding recommendations, identify local terms, develop the mother s card and ensure consistency of health education messages Conduct a national-level assessment of key family practices and available resources Collect and review existing information regarding key family and community practices Assess existing resources, opportunities and constraints to improve family and community practices Select the districts to initiate community-based interventions Review the core IMCI indicators at household level, and decide upon a process to monitor changes in keys family practices Build national capacity for IMCI implementation through training Train facilitators for the first central-level IMCI training course Conduct the first central-level IMCI training course(s) 90

6 vi IMCI PLANNING GUIDE 6.3 Train future course directors and clinical instructors for their roles in first district-level courses Finalize and reproduce the IMCI materials Develop district plans for IMCI early implementation (Conduct district planning workshops) Plan for improvement of skills of health staff Plan for improvement in the health system Plan for improvement in family and community practices Plan for documentation of early implementation Develop a district budget Compile the district plans Implement district-level IMCI activities Implement district-level IMCI training courses for first-level health workers Implement follow-up after training Implement solutions to improve the health system Implement community-based interventions Document progress and take action to solve problems Review the IMCI early implementation phase Summarize information on early implementation and prepare for review Review early implementation Plan for the expansion phase Agree on specific quality adjustments, based on what was learned in the early implementation phase Discuss structural and organizational issues Discuss how the IMCI strategy fits within the national health policy and, where relevant, health sector reforms Decide on emphasis and select activities for the expansion phase Decide on the general pace of expansion and the number of districts that will be included in IMCI activities during the next phase Select districts for expansion Plan activities in the districts Set targets for coverage and performance Plan for documentation and evaluation of IMCI 123

7 vii CONTENTS Plan a budget and compile the plans and recommendations into a summary plan for the expansion phase Conduct a consensus meeting to present the findings, recommendations and plan for expansion 123 Annexes 127 Annex A: IMCI national orientation meeting 129 Annex B: Methods and process for documenting IMCI early implementation 135 Annex C: Tools for data collection and summary 139 Annex D: Breastfeeding aspects of the IMCI strategy 147 Annex E: Drugs and supplies needed for implementation of IMCI 155 Annex F: Use and design of a translation table for IMCI and health information system classifications 157 Annex G: Review of the IMCI early implementation phase 165 Annex H: Priority IMCI indicators at health-facility level and at household level 199 Annex I: Milestones for IMCI implementation 207 Annex J: Selected exercises from the IMCI training course for first-level health workers: Participant s notes 211 Facilitator s notes 241 Answer sheets 249 List of figures Overview of the planning process for the IMCI Strategy 7 Figure 1: Components of the IMCI Strategy 5 Figure 2: Orientation meeting 12 Figure 3: Preparing for the national planning workshop: Checklist of useful information to gather if available 20 Figure 4: Preparing for the initial meeting of the Adaptation Subgroup: Checklist of useful information to gather if available 21 Figure 5: National planning workshop 25 Figure 6: Topics to cover in the national planning workshop 26 Figure 7: Possible sequence of activities for conducting training in Integrated Management of Childhood Illness 31 Figure 8: Essential activities for improving family and community practices 46 Figure 9: Key family practices for child survival, growth and development 47 Figure 10: Documentation of the early implementation phase: Areas and tools for collecting information 51 Figure 11: IMCI early implementation budget 56 Figure 12: Topics for the initial meeting of the Adaptation Subgroup 63

8 viii IMCI PLANNING GUIDE Figure 13: Ways to develop consensus and support for the adapted IMCI guidelines 64 Figure 14: Initial meeting of the Implementation Subgroup 70 Figure 15: Assessment of the district health system: Checklist of useful information to gather 72 Figure 16: Initial meeting of the Family and Community Practices Subgroup 82 Figure 17: How to build on and strengthen community resources to promote improved nutrition 87 Figure 18: District planning workshop 95 Figure 19: District early implementation budget 105 Figure 20: District plan for early implementation 106 Figure 21: Review meeting 115 Figure 22: Planning meeting for the expansion phase 118 Figure 23: Example table for planning activities: Section on training of first-level health workers 124 Figure 24: Outline of topics to address in the report summarizing the early implementation phase 170 Figure 25: Facilitator s notes for making a presentation on expansion 177 Figure 26: Issues relevant to the status and quality of IMCI implementation organized according to major areas 179

9 List of abbreviations ARI BFC CAH CDD Programme for Control of Acute Respiratory Infections Breastfeeding Counselling Department of Child and Adolescent Health and Development, World Health Organization Programme for Control of Diarrhoeal Diseases CHD Division of Child Health and Development, World Health Organization 1 EDC Essential Drugs Concept EDP Essential Drugs Programme FCP Family and Community Practices HIS Health Information System HSR Health Sector Reform IMCI Integrated Management of Childhood Illness MCH Maternal and Child Health Programme MOH Ministry of Health NGO Non-Governmental Organization UNICEF United Nations Children s Fund WHO World Health Organization 1 CHD has been combined with Adolescent Health and Development (ADH) to become the Department of Child and Adolescent Health and Development (CAH).

10 About planning for the IMCI strategy 1 A large proportion of childhood morbidity and mortality in the developing world is caused by five conditions: acute respiratory infections (mostly pneumonia), diarrhoea, measles, malaria, or malnutrition. The Integrated Management of Childhood Illness (IMCI) strategy encompasses a range of interventions to prevent and manage these major childhood illnesses, both in health facilities and in the home. The IMCI strategy incorporates many elements of diarrhoeal and ARI control programmes, as well as child-related aspects of malaria control, nutrition, immunization, and essential drugs programmes. An integrated strategy is needed to address the overall health of children for the following reasons: Most sick children present with signs and symptoms of more than one condition. Thus, more than one diagnosis may be necessary. Health workers need to be prepared to assess the signs and symptoms of all of the most common conditions, not simply those of a single illness. When a child has several conditions, therapies for those conditions may need to be combined. Health workers need to be prepared to treat conditions when they occur in combination. Care needs to focus on the child as a whole and not just the diseases and conditions affecting the child. Other factors that affect the quality of care delivered to children such as drug availability, organization of the health system, referral pathways and services, and community behaviours are best addressed through an integrated strategy. Implementation of the IMCI strategy in countries involves the following three components: Improvements in the case management skills of health staff through the provision of locally adapted guidelines on integrated management of childhood illness and activities to promote their use. Improvements in the health system required for effective management of childhood illness. Improvements in family and community practices. Implementing the IMCI strategy requires and facilitates collaboration between health programmes in a country, at all levels of the health system. The IMCI strategy does not involve taking responsibility for existing programmes, but re-

11 2 IMCI PLANNING GUIDE quires ensuring that activities are well-coordinated and implemented to contribute to IMCI. By improving the coordination and quality of existing services, the IMCI strategy will increase the effectiveness of care and reduce costs as countries work to achieve the following objectives: To reduce morbidity and mortality associated with the major causes of disease in children. To promote healthy growth and development of children. Phases of implementing the IMCI strategy Because IMCI is an integrated strategy requiring the commitment and full cooperation of a variety of health programmes, it is important to take time to build consensus and create a broad base of support as the strategy is planned and implemented. Countries are encouraged to adopt a gradual, phased process for planning and implementation of IMCI activities. The recommended process involves thorough orientation to, adaptation of, and experience with the IMCI strategy before expanding IMCI coverage and activities. The process involves three phases: introduction, early implementation of selected activities in a limited area, and finally, expansion of activities and geographic coverage. Introduction phase: The purpose of this phase is to orient and train key MOH decision-makers and staff to enable them to make an informed choice whether to adopt the IMCI strategy and, if so, to create a management and coordination group. In this phase decision-makers in the Ministry of Health receive information so that they may decide whether to adopt the IMCI strategy. Orientation meetings are held for managers in the health sector, as well as representatives of other relevant sectors, academic and training facilities, professional associations, donor agencies, NGOs, etc. Selected key national staff attend Integrated Management of Childhood Illness, the case management training course for first-level health workers, in another country, in order to better understand what is involved in implementing the IMCI strategy. If the Ministry of Health chooses to implement the IMCI strategy, this commitment is formalized by an official written endorsement and the creation of an IMCI Working Group to plan, manage and coordinate IMCI early implementation activities. The working group should have a coordinator who is a high-level member of the Ministry of Health and can effectively foster coordination among programmes and institutions represented on the working group. There should also be a focal person for the IMCI strategy in the country who is available for the day-to-day coordination of IMCI activities. In addition to the working group, it is an option to have a high-level national steering committee to review and validate policy decisions as needed. Early implementation phase: The purpose of this phase is to gain experience with IMCI planning and implementation through a welldefined set of activities within a limited geographical area.

12 3 ABOUT PLANNING FOR THE IMCI STRATEGY Once a commitment has been made to the IMCI strategy, a country should gain experience with the strategy in a limited geographical area, which will be used to guide future planning and implementation. In the early implementation phase, the IMCI Working Group develops a national plan for IMCI activities and selects the initial districts for early implementation. The working group coordinates the adaptation of the clinical guidelines and training materials for the country. The group plans for IMCI activities and helps prepare the districts to implement them. District health teams participate in planning and then conduct activities in the district, including several training courses, follow-up visits after training, and ensuring drug availability. Existing community-based programmes or interventions should be strengthened and utilized to promote family and community practices. The experience explores how the IMCI strategy will fit into the overall planning system at both central and district levels, how to link with health sector reforms, how much it costs, and how district capacity to do IMCI activities can be built. It includes a careful documentation of activities to identify and solve problems. At the end of the early implementation phase, there is a review of the experiences. Expansion phase: The purpose of this phase is to expand IMCI geographical coverage and activities based on the experience and lessons learned in the previous phase. Drawing on experience from the early implementation phase, the country plans how to expand IMCI activities in districts where IMCI activities were implemented on a limited scale and begins IMCI activities in other districts. A country may also broaden the range of IMCI activities within the three components of the IMCI strategy: improving case management skills, improving the health system, and improving family and community practices. IMCI evaluation activities begin in this phase. The IMCI Planning Guide What is the IMCI Planning Guide? The IMCI Planning Guide was developed by WHO to assist countries who want to undertake the IMCI strategy. It describes a phased process for planning and implementing interventions of the IMCI strategy and recommends steps for each phase up to planning for the expansion phase. The recommendations are based on experience in a limited number of countries. The guide sometimes describes different options and recognizes that countries may find various ways of carrying out the steps depending on their circumstances and ways of operating. Because the IMCI strategy is an integrated approach, staff and programmes will need to work together in new ways. Some important functions such as policy and guideline development, and setting minimal criteria for quality, will rest at the central level. However, most IMCI activities will be planned and implemented at district level. For these reasons, planning will require some innovative and cooperative approaches. Consensus-building, though it will take time, is essential.

13 4 IMCI PLANNING GUIDE The planning process will include some key events that bring together people from different programmes and institutions. The guide will describe these events in detail and will suggest additional ways to build consensus as plans and preparations are made. Who should use the IMCI Planning Guide? The IMCI Planning Guide is written for the persons responsible for planning for the IMCI strategy within the IMCI management structure, such as the IMCI focal person and the IMCI Working Group. It will also be helpful to other national and district-level planners, and external consultant advisors from WHO, UNICEF and other organizations who are assisting national planners. How do you use the IMCI Planning Guide? Suggested steps for planning and implementing the IMCI strategy are shown on the flowchart provided with this guide on page 7. The guide is organized according to this proposed sequence. A portion of the flowchart appears at the beginning of each chapter to show the context of the steps described in the chapter. However, there are other possible sequences; countries have proceeded in varied ways during the introduction and early implementation phases to accomplish the same steps. Persons responsible at the national level, including the members of the IMCI Working Group, should read the entire guide to understand the steps of planning and implementing the IMCI strategy. National and district-level staff involved in certain steps should carefully read about those steps in the guide. To prepare for and conduct a certain step, study the guidelines carefully, adjust them as needed, ensure any preparations are complete, and then conduct the step, referring to the guidelines as needed. Are there other tools that can help? WHO has developed some additional IMCI documents to help planners, such as the Adaptation Guide, 1 Guidelines for Follow-Up after Training, 2 the Course Director s Guide, 3 and Improving family and community practices: A component of the IMCI strategy. 4 These documents are used to prepare for and conduct specific activities such as adaptation, follow-up after training, an IMCI course, and planning of activities to improve family and community practices. 1 Integrated Management of Childhood Illness. Adaptation Guide, A guide to identifying necessary adaptations of clinical policies and guidelines, and to adapting the charts and modules for the WHO/ UNICEF course, Working draft November 1999, WHO/CAH 2 Guidelines for Follow-Up after Training in the WHO/UNICEF course on Integrated Management of Childhood Illness for first-level health workers. WHO/FCH/CAH/ The Course Director s Guide, Integrated Management of Childhood Illness, WHO/CHD/97.3.K Rev.1 4 Improving family and community practices: A component of the IMCI strategy, WHO/CAH/98.2

14 5 ABOUT PLANNING FOR THE IMCI STRATEGY What is the role of external consultants in planning for the IMCI strategy? National planners are encouraged to ask for help from WHO, UNICEF and other partners to carry out some of the key activities for planning and for adaptation. There are some events for which the help of an experienced person may be required. These events include: A preliminary visit to discuss the IMCI strategy with the MOH An orientation meeting at the national level The national planning workshop An adaptation workshop The consensus meeting about clinical guidelines Special studies The first central-level training course in IMCI case management The first follow-up after training workshop and field visits, and The review and replanning meeting FIGURE 1 Component of the IMCI strategy Improving case management skills of health staff Improving the health system Improving family and community practices Possible activities in early implementation phase Adaptation of generic guidelines and training materials on integrated management of childhood illness at the firstlevel health facility IMCI training courses for first-level facility health workers Follow-up visits after training to reinforce skills of health workers Guidelines and training to improve skills at referral-level facilities Ensuring availability of drugs needed for IMCI through improving supply and management Improving referral pathways and services Improving organization of work at health facilities Improving supervision of health services Linking IMCI classifications and the health information system Providing health education and counselling to mothers about feeding children and care of a sick child, with improved counselling skills of health workers Ensuring that consistent messages about child health are given to families Implementing community-based interventions to promote child health and development

15 6 IMCI PLANNING GUIDE Components of the IMCI strategy The IMCI strategy involves three components: improving case management skills, improving the health system, and improving family and community practices (Figure 1). References to these three components appear throughout the guide.

16 OVERVIEW OF THE PLANNING PROCESS FOR THE IMCI STRATEGY 1.0 Introduce the IMCI strategy Page Develop a national plan for the IMCI early implementation phase Page Adapt the generic IMCI guidelines and training materials Page Initiate activities to improve the health system and prepare for health worker training Page Initiate activities to improve family and community practices Page Build national capacity for IMCI implementation through training Page Develop district plans for IMCI early implementation Page Implement district-level IMCI activities Page Review the IMCI early implementation phase Page Plan for the expansion phase Page 117

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18 1. Introduce the IMCI strategy 1. INTRODUCE THE IMCI STRATEGY 1.1 Review initial information about the IMCI strategy 1.2 Orient important groups and individuals to the IMCI strategy 1.3 Establish an IMCI management structure 1.4 Train key personnel to manage sick children according to the IMCI guidelines 1.5 Ministry of Health endorses early implementation of the IMCI strategy WHO information materials Internal MOH discussions Pre-visit Orientation meeting MOH decision IMCI course in other country (in very large country, a demonstration course) WHO workshop on planning and adaptation Official MOH statement The overall goals of the introduction phase are: To create a good understanding about the IMCI strategy including all three components To enable decision-makers in the health sector to make an informed choice whether to adopt the strategy To encourage full participation of staff in the planning process To agree on a management structure for early implementation of the IMCI strategy To train a few key staff members in preparation for planning and early implementation of the IMCI strategy To encourage the Ministry of Health to demonstrate commitment to explore the potential of the IMCI strategy by means of the early implementation phase Initial interest in the IMCI strategy usually arises from someone or a group charged with child health, such as the MCH programme or Child Health Division. They may require the assistance of an experienced consultant to guide the country through the introduction phase and to be present for orientation meetings. The steps in this phase are described in this section.

19 10 IMCI PLANNING GUIDE 1.1 Review initial information about the IMCI strategy The description of this and the next step (1.1 and 1.2) is directed to the individual or the group who stimulates the interest in the IMCI strategy in the country. The rest of this guide is addressed to the persons responsible within the IMCI management structure, such as the focal person for IMCI. To initiate the discussions about IMCI in the country, send official requests for information from the Ministry of Health to WHO, UNICEF or other organizations with suitable experience, so that the country will receive a well-informed response. It is important that the IMCI strategy is well understood from the beginning Review specially prepared generic materials on the IMCI strategy and its implementation, which can be obtained from WHO, UNICEF or other organizations These materials include: The WHO IMCI Information Folder Integrated Management of Childhood Illness (IMCI): a joint WHO/UNICEF initiative Improving child health, The role of Integrated Management of Childhood Illness (IMCI), Division of Child Health and Development, WHO Hold initial discussions among senior decision makers, reviewing the specific information obtained and discussing: The nature and scope of the IMCI strategy How the IMCI strategy relates to the needs of the country The process of implementing the IMCI strategy gradually, in phases The implications for organization and resources (estimates of likely costs and effectiveness) Planning for a wider orientation, including a formal orientation meeting and technical meetings with groups and programmes Involve the highest possible levels of the Ministry of Health in individual or small group meetings to discuss the IMCI strategy. They should learn enough about IMCI that they could chair subsequent meetings from a position of knowledge. Include in the discussions donors and other partners, including NGOs who are interested in improving child health in the country, if this is appropriate and useful. It can be very helpful to request that a consultant trained in planning the IMCI strategy make a preliminary visit. During the preliminary visit the consultant can help hold these important discussions and discuss implications of introducing the IMCI strategy in a country.

20 11 1. INTRODUCE THE IMCI STRATEGY Helpful materials for these discussions and the orientation meeting described in step 1.2 below include the items listed above (in 1.1.1) and: Available information about the country: epidemiological data on childhood illness service data on case management of childhood illness household study data The outcome of this step may be a decision to pursue further discussions and plans by means of a structured orientation to the IMCI strategy for the Ministry of Health and other groups. Some countries are then able to move quite quickly through initial steps of the introduction phase (steps ), accomplishing them almost simultaneously; some countries require several months. Or, a country may decide not to pursue the IMCI strategy at this time, recognizing that some important preliminary activities are needed before engaging in the IMCI strategy. 1.2 Orient important groups and individuals to the IMCI strategy (orientation meeting) If there is an interest in the IMCI strategy, plan a formal orientation meeting. The orientation meeting provides an opportunity for a large group of stakeholders to reach a common understanding of the concepts and practical principles of the IMCI strategy, and its advantages and implications for the health system. The format and duration of the meeting may vary, depending on the depth of the discussions that have already taken place and the readiness of the country to move forward. If few discussions have taken place, and the Ministry of Health needs more elaborate information about the IMCI strategy, it will be useful to conduct a two-day meeting to provide information and reach a common understanding. If substantial discussions have already taken place with the help of an experienced person (as in a preliminary visit), the Ministry may be ready to commit to the IMCI strategy. In this case, it will be useful to extend the orientation to include steps to prepare for the national planning workshop. Annex A describes different options for conducting the meeting. Use the annex to decide on the most appropriate option and prepare for the workshop accordingly. Figure 2 summarizes key aspects of an orientation meeting. Look for a person with experience in planning IMCI to help plan and conduct the orientation meeting and advise on a management structure (perhaps a consultant from WHO, UNICEF or another organization). Informal meetings to generate and maintain interest may precede or follow the orientation meeting. 1.3 Establish an IMCI management structure The Ministry of Health, in coordination with other key actors, should establish a management structure for coordination of the early implementation of IMCI activities. The structure should:

21 12 IMCI PLANNING GUIDE FIGURE 2 Orientation meeting Objectives To provide information and reach a common understanding on the concepts and practical principles of the IMCI strategy, its advantages and implications for the health system To discuss the need and explore options for a management structure to coordinate the implementation of the IMCI strategy To obtain commitment to initiating the early implementation phase in order to gain experience with the practical application of the IMCI strategy Participants Programme managers and technical staff of programmes involved with IMCI, such as MCH, CDD, ARI, EDP, malaria control, EPI, nutrition, HIS, training, etc. Other related ministries and bodies: Rural Development, Education, Social Welfare, Planning, etc. Actual or potential partners: bilateral and multilateral agencies, NGO s, health-related institutions Academic and training faculties Representative from medical association, nursing association Duration Two to four days, depending on the country s needs Methods Interactive mix of presentations and discussions Topics See agenda in Annex A Involve all major concerned parties, at least technically, in decision making, so that they may feel ownership of the IMCI strategy Have the authority to make decisions across programmes Have the authority and resources to make day-today decisions on the implementation process without delay A structure that has been shown to work includes an IMCI Working Group, a coordinator for the working group, and a focal person for the IMCI activities. In addition, some countries may wish to have a higher-level steering committee. IMCI Working Group: The working group will guide and support the ongoing planning and management during early implementation. This small group should include staff of relevant programmes (such as ARI, CDD, MCH, malaria control, nutrition); representatives from the national drug programme, national breastfeeding committee, and organizations involved in community-based interventions; representatives of university departments and important institutions; paediatricians and interested partners. Programmes should nominate a member for the working group who can make the time commitment to carry out IMCI activities. The working group will have the shared responsibility to carry out the activities in the early implementation phase: Provide technical support and advice to the IMCI focal person Carry out the steps of adaptation of the IMCI guidelines and training materials Plan and implement activities at the central level, and assist districts in building capacity for planning, implementing and documenting IMCI activities at district-level Facilitate the coordination of concerned programmes and groups It has proven advantageous to organize the working group in two or three subgroups: The Adaptation Subgroup focuses on adaptation. Its members are technical staff from concerned programmes, pediatric association, academic institutions. The Implementation Subgroup focuses on planning for implementation and data collection at the central and district levels. Its members are staff with substantial programme experience.

22 13 1. INTRODUCE THE IMCI STRATEGY The Family and Community Practices Subgroup (optional) focuses on planning for implementation of interventions for this component. Its members should include key persons who are working with communities and families. It is important that appropriate staff from district level become involved in planning as soon as possible. Each subgroup needs a coordinator to schedule meetings and organize the work. The IMCI focal person may serve as coordinator of one of the subgroups. Some members may serve on one or more subgroups, though this may be limited by the time they are able to devote to working on IMCI activities. As soon as the early implementation districts are selected, representatives from the districts should join each subgroup. The full IMCI Working Group should meet regularly during early implementation so that the subgroups can update each other on their work and share information. IMCI Working Group coordinator: The IMCI Working Group should have a leader or coordinator who is a senior member of the Ministry of Health and can effectively foster coordination among programmes and institutions represented on the working group. Designating someone for this role who is at a higher organizational level than the managers of the technical programmes will facilitate coordination. This individual should be a well-respected person to whom the paediatricians and others on the working group will respond. In addition he or she should have the authority required for making and implementing the decisions of the working group, including advocating for the IMCI strategy and allocating resources for its implementation. IMCI focal person: The Ministry should be encouraged to assign at least one person to work full-time on IMCI activities. This focal person has the day-to-day responsibility for ensuring that planning and implementation moves ahead at a steady pace. The IMCI focal person is a member of the working group, but probably not the coordinator. The focal person will manage and facilitate the IMCI activities, such as by inviting members of the working group to meetings, circulating information, and participating in and supporting the work of the subgroups. The individual selected for this role should have a medical background, ideally in paediatrics, and programme experience. The focal person should have secretarial and administrative support. Where possible the IMCI Working Group and the focal person should be supported by an IMCI secretariat, consisting of several staff who can dedicate a substantial amount of their time to IMCI-related activities on a regular basis. This becomes particularly important once the implementation of activities at district level has started, when there will be a demand for managerial support from the central level. A high-level steering committee: (Optional) Some countries may consider having a small committee (4 5 people) that includes a few essential senior Ministry of Health officials, and advisers from senior faculty of universities and institutions. The IMCI Working Group coordinator would be on this committee. The committee would:

23 14 IMCI PLANNING GUIDE Review and validate the work of the working group and Facilitate higher-level policy decisions as needed. At the district level, a district focal person and the district health team: In districts, health activities are usually managed by the district medical officer and a district health team of 5 10 people which may include some nurses, public health inspectors, and doctors. In each early implementation district, the district medical officer or an appointed member of the team should be a district focal person for IMCI. This individual should coordinate with the central level, including the IMCI Working Group and its subgroups. The focal person represents the interests of the district, helps the central level plan for activities in the district and helps the district health team obtain advice and support needed from the central level. Alternatively, the IMCI Working Group in consultation with the district health team may decide to establish a district IMCI Working Group. This will enable the district health team to co-opt representatives from other sectors and organizations to plan and implement IMCI activities. Some countries already have established district health management teams that are an extension of the district health team, to meet these objectives. Whatever the organizational arrangement chosen, it is important that the IMCI focal point has a close link with the district health team and therefore is a full member of it. The long-term success of the IMCI strategy will depend in part on whether there is effective coordination of the concerned programmes. Countries will evolve a suitable structure for this coordination, drawing on the experience of the early implementation of IMCI. 1.4 Train key personnel to manage sick children according to the IMCI guidelines Key personnel in the IMCI Working Group need to be trained to manage sick children according to the IMCI guidelines by participating in a standard 11-day course for first-level health workers. This is essential so that they can lead the IMCI Working Group to adapt the case management guidelines and plan for IMCI training courses and other activities. As soon as the IMCI focal person and members of IMCI Working Group are designated, the Ministry should discuss with WHO, UNICEF or other child health organizations how to train key persons. Discuss arrangements for sending to an IMCI training course at least the IMCI Working Group coordinator, the IMCI focal person and the coordinators for the Adaptation and Implementation Subgroups. If there is to be a community subgroup, the coordinator should also be included. A donor may support participants going to a course in another country where fully adapted materials have been completed and courses are underway. There may also be an opportunity for someone to participate in a WHO workshop on planning and adaptation. In some countries, where it is essential to have a larger group of people that are knowledgeable about IMCI in order to get commitment to proceed, an option is to conduct a demonstration IMCI case management course. A demonstration

24 15 1. INTRODUCE THE IMCI STRATEGY course is conducted with only minimally adapted materials. Experienced facilitators are brought from outside the country. Though it is costly, it allows a large number of people to learn about the IMCI clinical guidelines, how a course is organized and how it works. However, there is very limited experience with demonstration courses and there is known difficulty preparing and using a course with minimal adaptations. It may be better for key staff to participate in a course in another country where adaptation has been completed and implementation of courses is underway. This knowledge will be especially important for the individuals who plan early implementation, such as the IMCI focal person and subgroup coordinators. 1.5 Ministry of Health endorses early implementation of the IMCI strategy The long-term future of the IMCI strategy in a country depends on acceptance and commitment from the Ministry of Health and other groups. As each country has to find the best way to implement the IMCI strategy, it cannot be expected that the Ministry will express full commitment to long-term implementation before the health system has gained some experience. However, even the introduction of the IMCI strategy involves existing programmes and staff working in new ways. Therefore, it is essential that the Ministry of Health officially endorse the steps of early implementation. In order to facilitate coordination, enhance credibility with partners and increase visibility of the IMCI strategy, the Ministry should prepare and issue an official statement announcing: The Ministry s decision to implement the IMCI strategy, beginning with carrying out an early implementation phase The management structure for IMCI, including the membership of the IMCI Working Group, the working group coordinator and the IMCI focal person The Ministry of Health authorizes appropriate staff time of all concerned programmes to collaborate with the early implementation of the IMCI strategy. The Ministry of Health should send this statement to all concerned programmes within the Ministry, with a covering letter directing them to collaborate in the early implementation of the IMCI strategy. The official statement should be widely distributed, including being sent to universities, and partner organizations that attended the orientation meeting. As soon as the Ministry of Health has made this endorsement of the IMCI strategy, the country should proceed quickly to prepare a national plan for the IMCI early implementation phase (step 2.0 below). This plan will help to ensure that activities proceed in a coordinated way. If development of a national plan is delayed, and adaptation or other activities begin anyway, inefficiencies and confusion are likely.

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26 Overview of the IMCI early implementation phase STEPS IN THE EARLY IMPLEMENTATION PHASE 2.0 Develop a national plan for the IMCI early implementation phase 3.0 Adapt the generic IMCI guidelines and training materials 4.0 Initiate activities to improve the health system and prepare for health worker training 5.0 Initiate activities to improve family and community practices 6.0 Build national capacity for IMCI implementation through training 7.0 Develop district plans for IMCI early implementation 8.0 Implement district-level IMCI activities 9.0 Review the IMCI early implementation phase During the early implementation phase, the country will gain experience with implementation of IMCI activities at the central level and in a small number of districts (2 or 3). Early implementation includes planning, adapting clinical guidelines and training materials, building training capacity at the central and district levels, and conducting training courses and follow-up visits. It includes activities to strengthen the health system, such as ensuring the availability of drugs needed for IMCI. It explores how the IMCI strategy fits into the overall planning system at both central and district levels, how it links with health sector reforms, how much it all costs, and how to build district capacity to do IMCI activities. This phase also includes carefully documenting activities to quickly solve problems. The information on activities is organized for a review after about one year of implementation in order to strengthen future plans. Step 2.0 is done by the whole IMCI Working Group. Then three blocks of activities are done simultaneously by the subgroups: Step 3.0 is done by the Adaptation Subgroup and focuses on adaptation of IMCI clinical guidelines and training materials, and then the preparation and production of materials.

27 18 IMCI PLANNING GUIDE Step 4.0 is done by the Implementation Subgroup, including staff from the selected districts. It includes orienting and beginning work with the districts. Step 5.0 is done by the Family and Community Subgroup, if the IMCI Working Group decides to form one to address the major issues regarding the promotion of key family and community practices. Otherwise this step is done by the Adaptation Subgroup. Steps 6.0 and 7.0 are then done at approximately the same time. Step 6.2 is the first IMCI case management course at the central level. Some district staff should be trained in this course before doing planning and preparations in the district (step 7.0). Step 8.0 is carried out at the district level, by district staff, with some involvement and support from the central level. Step 9.0 is the responsibility of the central level, with participation of district staff. A country may feel the need for some technical assistance from a person with experience implementing the IMCI strategy, such as a consultant or representative of WHO, UNICEF, or another organization. This assistance may be most helpful with several key steps in the early implementation phase, specifically: The national planning workshop (step 2.0) The first meeting of the Adaptation Subgroup (step 3.1, also called adaptation workshop) and the consensus meeting about clinical guidelines (step 3.3) First central-level IMCI training course (step 6.2) First follow-up after training (steps 8.2.2) Review of the early implementation phase (step 9.0)

28 2. Develop a national plan for the IMCI early implementation phase DEVELOP A NATIONAL PLAN FOR THE IMCI EARLY IMPLEMENTATION PHASE 2.1 Gather information for planning the IMCI strategy Review of available data, reports, descriptions Informal assessments, interviews 2.2 Decide on organization and management and develop terms of reference for the IMCI Working Group 2.3 Develop a national plan for the IMCI early implementation phase National planning workshop Meeting of the IMCI Working Group The first step in the early implementation phase is the development of a national plan. A national planning workshop is a feasible way to achieve this. In preparation for this workshop, there is a need to gather information and formalize the IMCI management structure. The outcome of this step is a national plan for the early implementation phase that forms the basis of all steps and tasks that will follow. 2.1 Gather information for planning the IMCI strategy The national planning workshop (step 2.3) and the initial meetings of the subgroups (steps 3.1, 4.1 and 5.1) will include discussions and decisions that should be based on accurate information about the current health situation and services. To prepare for these meetings, this information should be collected and then prepared for the members in a clear and organized format. The recommended approach is to gather only information that is essential for planning of clinical guidelines, for setting priorities and for planning activities in the three components of the IMCI strategy. Figures 3 and 4 list information to gather prior to these meetings.

29 20 IMCI PLANNING GUIDE FIGURE 3 Preparing for the national planning workshop: Checklist of useful information to gather if available 1. Major causes of morbidity and mortality in children in the country 2. Health facilities: structure of health system, approximate numbers, types of health facility, utilization of health services 3. Current case management practices (compliance with national policies) 4. Target group for training: categories of health workers managing sick children and approximate number of each 5. Information on how inservice training is currently organized (e.g., for CDD/ARI, MCH, nutrition): methods, availability of clinical trainers, etc. 6. Existing training sites and possible central-level sites for IMCI case management courses 7. Any ongoing health sector reform efforts 8. Major partners in child health 9. Availability of drugs and supplies: supply and distribution to health facilities in districts 10. List of generic drugs that are needed for IMCI case management 11. Usual referral practices at first-level facilities when severely ill child needs additional care 12. Description of current monitoring and supervisory systems at the district level: job descriptions, data on quality and frequency of supervisory visits, types of monitoring tools 13. Description of existing health information system (HIS): how it performs including frequency, type of information collected, methods, forms, and how information is used 14. Some information on a few likely districts for early implementation, if known: accessibility to central-level staff, availability of suitable training sites, accessibility of referral of severely ill children from first-level facilities, availability of drugs, committed staff, support by partner organization 15. Any available information on careseeking patterns, caretaker recognition of illness, and home care practices 16. A brief summary of who is doing what with regard to communitybased child health and nutrition promotion 17. Information on existing interventions to improve family and community practices